Reference Book

Why is the new revision of Diagnostic and Statistical Manual of Mental Disorders (the “DSM-V”) — the reference book used to diagnose mental disorders in the U.S. — being updated in secrecy?

That’s a legitimate question, and one asked by the previous head of the other modern DSM revisions (III, III-R and IV), Dr. Allen Frances in an upcoming Psychiatric Times article:

The secretiveness of the DSM-V process is extremely puzzling. In my entire experience working on DSM-III, DSM-III-R, and DSM-IV, nothing ever came up that even remotely had to be hidden from anyone. There is everything to gain and absolutely nothing to lose from having a totally open process…

You’d have to ask Dr. David Kupfer, the head of the DSM-V revision process, or the American Psychiatric Association, the folks responsible for the update, but they aren’t talking. We last wrote about this issue in November 2008, and apparently little has changed in the past seven months.

Dr. Doug Bremner has the continuing saga of the groups of dozens of professionals and researchers who have been sworn to secrecy in their work on revising this important book. But even more disturbing is that people are so upset about being called out on the lack of openness and transparency in the process, they are now using intimidation and “blacklisting” to try and silence the DSM critics:

Add to Dr. Kupfer’s [the head of the DSM-V revision] strategy of: 1) keep everything a secret; 2) make members sign confidentiality agreements; 3) allow no note taking; 4) ignore outside experts and comments; we can now add, 5) intimidate and ostracize academic psychiatrists whom you can’t ignore.

Dr. Bremner was dis-invited by email in co-authoring a research paper on an unrelated topic because of some very indirect criticism he posted in a previous blog entry. The email came from “someone on the DSM Anxiety, OCD, PTSD and Dissociative Disorders committee:”

What was particularly chilling about this episode is that the email was copied to all the members of the committee, implying that I was now persona non grata and should be shunned by what are in fact my peers in the anxiety disorders and trauma community of academic psychiatry.

Reasoned and thoughtful criticism is the hallmark of science. The whole point of publishing in a peer-review journal isn’t just to get the information out there — it’s to get it out there in a form that other scientists and researchers can understand and reproduce (if they want), so the entire field can move forward in their knowledge. That also means criticizing the work when it is lacking, cannot be reproduced, or has obvious flaws in methodology or logic.

Sadly, academics who can’t take criticism are more common than you might imagine. And the more senior you become in a particular research field, it seems the less able you are to take criticism or feedback.

Sure, it can be difficult to see your methods or procedures being dissected or criticized on a blog, such as Dr. Bremner’s. But that comes with the territory.

But Dr. Bremner’s case is not necessarily unique. You anger the wrong people in a passing sentence in a blog entry, and you can be denied professional opportunities. Dr. Carlat suffered a similar fate not because of something he wrote on his blog, but because a commenter wrote something critical of the DSM-V process that Dr. Carlat did not remove quickly enough to the satisfaction of those in power at the American Psychiatric Association. It seems that if you publicly criticize the DSM-V process, you are going to anger folks at the American Psychiatric Association.

These episodes — and the amount of politics one must play — are key reasons I have little interest in academia. If I have to worry about every word I write might be mis-portrayed or misunderstood by someone who could deny me a future professional opportunity, I’d just quit writing. (Of course, things I’ve written have likely denied me certain opportunities anyway, but at least my career doesn’t depend on them.)

I’m not certain this is what Dr. David Kupfer, the head of the DSM-V revision process, had in mind when he originally implemented these policies of secrecy surrounding the revision of the DSM. Perhaps he thought it was in the APA’s best interests to keep it as private a process as possible, but in this era of increasing openness and transparency, the APA made the worst decision possible.

Dr. Kupfer could still redeem himself, if he had any interest in doing so. So I’d like to call on Dr. Kupfer and the American Psychiatric Association to answer these issues, and explain to the public — the folks who will suffer for better or worse as a result of the DSM-V — why such an important reference manual is being updated in such secrecy.

Philip Dawdy over at Furious Seasons also has a good summary of these two issues, which is also worth the read.

Read Dr. Bremner’s article: DSM-V Shadow Team: Retaliations & Beware of Consequences

Read Dr. Carlat’s article: The APA, Power and the Exclusion of Dissent

Read Philip Dawdy’s take on it: Psychiatrists Attacking Psychiatrists For Blogging On Disclosure Controversies